B 0353 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY nF CUPERTINO BUILIIING-MECH N ICA PERNII 1 0353
BUILDING DIVISION APPLICATION/PERMIT PLUM PROJECT
SOOOI
BUILDING 1'NUJECT IDEYTI4'ICA'TION
%ANIUKY NO. AI'I'LICATION SUlih111'I'AL UA'1'
BUILDING ADDRESS:
t��a ��pJOW 'N'S NAME: ZONE: C ACTORS NAME: LIC NU:�TJ�T NIC CONIROLa
gRCHITECI' IN
E' LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Cnn..ltant Fees Paid by Applicant(Initial) BI❑DC IiLlicl PLC
B M11
1
I.ICENSIiD CONTRACTOR S DECLARATION QTY, ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hcmby affirm that 1 am licensed under provisions of Chap¢r 9 mom ursamg
,C)Z with Sevelon70(mwfDivision 3 of the Bnvi nes.and Pndessions Code.anA my license is {� RESIDFiNT1A1.:
g20I-1mX)AMPS
SSIIANCE ( y `J
�LL� in full force zndcffco. ❑SFDWh ❑KI'I'CIIEN RI3MODIi1.
aUU Liccnsc Class LW.Of CES-RESIDIds TIAL ❑ADDUION ❑PLUMBING ITH-PIPIT
y4L Dan Cmactr ❑MULTI-UNIT C]STRUCTURAL
ARCIIII'ECI"S DECLARATION n MODIFICATION
OZti? 1 understand my plans shallM used as public records L ^L' 2—
p❑ d PS ❑INTI3NIOR ❑CIIIMNI3Y REPAIR
C✓�,E'„IY Liccnsul l•ro[cssiond IMPROVEMENT SWIMMING POOISOWNER-BUILDER DECLARA'1'TON ❑HATH R13MOUI?IJILEI'All< DIiMOLITION
I hcrcby unirtn that I am exempt from the Contractor's License law fur the X)AMP5
7(O q U following maV m.(Section 7031,5,Business and Professions Cudc:Any city or amnty SIGNS ELECTRICAL ❑DTH13N
W 3 LL N 'im,t it,liras n permit t^nae,The alter,improve,demolish,nr repair any amnnre
F'1=•fig priorwik tensed dAsnil1.a s prevision,o for such Cramisnnin Livcrole a sEnedamemem SPECIAL CIRCUIT/MISC.
f,w}
that he is licensed pursuant etre provision,of the Contmcmrs License Loons Code)or
FR 1
t?d�p0 (commencing with Sution]gXBol'Division 3 of the Business and Professions C�de7 or TEMP.MEI'IiN OR POLE INST.
a a e C
Ohio he is exempt thctefmm end the basis for the alleged exemption.Any violation of NEW 131.DG/ADDITION ❑D13MOLIIION
WaySection 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOODSERVICI3
not more than five hundred dollars(55101. IMPROVEMENT
fZ� 0Lmowner of the propcny.nr my employees with wages uslhcir sole cuntpensatinn, SWIMMING IDOL FI.F.CTRIC
4., will do the work.and theswemre is oro intended or offered for cle(Sec.9044.Business ❑OTIII3N
W3.3w and professions Code:The Commnorn I.Icemc Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
prapctty who builds or improves thereon,and who does such work himself nr through
his an employees, av kIA1 that such improvements are not intended or offered for NEW RESIDEN A fI.FCTR SO FP.
sale.IL howeect,the building or improvement is and within nam year of completion.the SV.f9'.FLOORAREA, %/SO.FI
ser-builder will have the burden of proving that he did not build or improve for put-
u Imlc,). ITO Q
of the pmpemy,am exclusively contracting with Iian.wJ contractors to D
amsauct the project(Sec.7144,Business and Professions Code:)The Conv ctnr's Li-
seL,w does notapply to an owner of propcny who baimxor imprneex tnemom.and QTY. NG PER FEE
twnocotnmets lot such pmjacd with acontrarlm(s)licensed pursuant num Comoclms MAY 1 01999
_ Lecnse law. PERMIT ISSUANCE
*.�fiuu,
lam use oder Sec. ,B&PC for this mann
AI:1'IIR-UNAIN&VIiNT-WA (EAI VALl1ATION
ne still
KASCO 3NSATION DECLARATION BACK FLOW PROTECT.DEVICEIh yat Under pe^vltynlcrjary one of the following declaration:Ihuvcund will maintainu Ccrificalc of Cotsunt to sdhit¢umlor Wnrmr,Contpcn- DRAINS—FLOOR,ROOEAREA.COND. STORIES as provided for by Section 3700 of The Labor Cole,for me performance-1 The ,
work for which this permit is issued. FIXTURES—PER TRAP
1 have and will mninmin Worker's Compensation Insurance,as required by Section GAS—EA.SYSTEM-I INC.4 OUTLETS -GROUP
370of the labor Code.for the perbeaencc of the work for which this permit is issued
(ICC APN
My Worker's Compensation Insurance eerier and Policy number arc: GAS—EA.SYSTEM-OVER 4 TEAT
Canter: Policy No.:
C17RI']FICATE OP EXEMPTION FROM WORKERS' GNI3ASFJINUUSTRI,WAS"TIi1MTERCI3YIY)R
COMPENSATION INSURANCEBI3II.OING DIVISION FEES
(This section neednot becompleted ifthe Permit is laranehundmddollars j$I0H GREASETRAP PLANCIIECK FEh
or Tc.s.)
I ocrufy that inthe pe,moda erof the work for which this permit is issued.l shall SEWER—SANITARY—S'I ORM EA.2Nd 11'. ENERGY FEE
not employ any Perman in any manner m.us Income subject to the Workers Compen-
,Z sidom Lnws of Cnlifnmla.Dam W'AT'ER HEA'IF,R W/VENT/ELECTR GRADING FEE
ZApplicant
y
NOTICE TO APPIJCAWn If after making this Cedificam of Bxcmpnon.you should WATER SYS'TUM/I"RIIAI'ING
F" bcomembjed,othe Wodcrs Compemmoon provisions of the latan Code.you most
SOILS hlili
WQ d'onbwith comply with such p,wi,io omthis permit shall he deemed mvaked. WNI'ER SERVICE.
0.
CONTTRUCUON LENDINGAGENCy NEW RLSIDHNTIAL 1'LMB, SQ.I'1'. PAID
Receipt p
VQ Thereby ufti^n That hem is a construction lending agency for the performance of
)..r
'he work for which this permit is i,umed(Sec,3099.Co.C) Tf lAl.:
OU Lenders Name
TOTAL:
r U1Leader's AdJress NUILDING T
1 candy That I have read thi.u;gpllceion and state that the above information is
Fr CPA, c rest.I agree ,,comply oth all city and countyordinance,and sum laws relming to QTY. MECHANICAL PERM IT IsEE SEISMICIl'i
U Z building construction.and hereby rename mpmsericarives of this city to enterupon the
abovennenlimned pmpcny for inspection Puaaws PERMIT ISSUANCE 13LECTRI FET:
(We)agree Bo xavI. omenand and keep hamlex,the City at'Cupcmino against
lixhilities,jvdgments,costs and expenses which may in any way accrue egmnst ad City ALTER OR ADD TO MECH. I'LUM141NO 'Eli
in quence of the granting of this Permit.
APo,.mc'ANI'UN UP RS' ..IANDS AND W )MPLY WITH AL1.NON POINT AIR HANDLING UNIT(TO TO."CFM) MECDANICA FEF.
SO
UN(E ".A'10 AIR HANDLING UNIT(OVER I0.0()0CFM)
CONS'I'RUCTION'1AX
ammo PplicunUG vaor Uma EX11AUST000D(W/DUCO IiousRsOlornosiONFE,
HA' RUOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle heavNous nemrial HEATING UNIT(TO II d.ddd B'1'U)
us dollncd by Thu C.Ndino Munielpal Code,Chapter 9.12.and the Health and Safety 1117ATINO UNIT(OVER 100.001 B'I'U)
Code,Section 25532m)1
❑Yes L7f4or VCNTILAIHIS IAN ISINGLE RCSIU) PAID
• Dae Receipt x
Will the sit omunl mr fuwin building by The a um Area
Air Qu or Maas which 11UILER—COMP(3110 OH IINI,INN113'N)
mit hvaNuus air conuminants es def ncJ by the Bay Arca Air Quality Management )fI
iatieY! L_7!N/ TOILER—COMP(OVER IBB(NNI BTU)
Cl YO,
1 have red the h odr.Section,
255 requimmemx under .I mar 6.95 of the if be
AIR CONIC HONER ISSIJANCE DAII'E
f^mia Hcaph&Safety Gxk.Sections 25505,I 3 n 55311 a notify me
that if the NEW RESIDENf1A1.MECH, SQ.Fp.
huik' g11snntcurtcnllyM1nv ,fa ;rots Nut it tyyyyl.yrs .bilitylnnoti(ythc ocaupmn (/
of tl c rcgU'ones s which ams M m nq tojpaa a cnitiamc of Occupancy. % D
m `Iwo f ugcn ` Dec TOTAL: ISSUED BY:
OFFICE I